Whipple procedure have described by Allen Oldfather Whipple Era in year 1935. This operation is the one of biggest surgical procedures in general surgery. For this reason, it is important to know the surgical anastomoses and removed pieces. Whipple surgery is one of the largest surgeries of the general surgeon commonly referred for diseases that involving the pancreas, main bile ducts or both hepatic ducts. This operation have known as pancreaticoduodenectomy too. It is the most difficult operation after transplantation on the list of surgeries that the general surgeon can do alone. This operation has a high mortality and morbidity risk due to complications also.
Whipple surgery may usually required in patients diagnosed with pancreatic cancer. Although, in pancreatic cysts that disrupt pancreatic ductwork may require this procedure also. Developing necrotizing pancreatitis and pseudocyst due to untreated pancreatitis attack may require sometimes whipple procedure too. Tumors that involve the main bile ducts, klatskin tumors with special name are cancer that usually Whipple surgery can not successful completed. For this reason, this cancers life expectancy is poor. Neuroendocrine pancreatic tumors is an other indication for whipple procedure. If the surgery will end successful, This patients can survive 8 to 10 years. Steve Jobs the creator of Apple company has neuroendocrine type pancreas tumor. So, he have survived up to 8 years, after Whipple surgery. There was no affect of money or being rich. Another rare indication for surgery is traumatic pancreatic fracture.
MRCP (Magnetic Resonance Choledochary Pancreatico-X-ray) must performed to all these these patient and the condition of the pancreatic tumor, cystic lesion and choledochal canal should observed before surgery. Lung film should definitely done before surgery also. Blood tests like liver enzymes, AST and ALT level, full blood count, kidney tests, creatinine level, bleeding values, INR, aPTT and PTT should be done and absolutely 4-6 units blood should be prepared before entering to surgery. Contagious diseases may questioned and if the patient have weight loss history and if he have fatigue, parenteral nutrition solutions should used for 5-7 days to fix this findings before performing the surgical procedure. The Hgb value must be above 10 mg/dl. Central catheter should inserted in these patients before the operation also.
In this procedure; pancreas penetrated tumorous area, distal choledoch, duodenum, ampulla vateri and gallbladder must removed together. The pancreatic duct anatomically merges with the choledoch and flows from ampulla to duodenum. For this reason, pancreatic duct and the choledoch remains open. Because the excision of duodenum, the stomach bottom will also remain open. The stomach should anastomosed to distal jejunum. But, this is the easiest anastomosis that may performed at last row to not narrowing the surgical area.
First, the pancreas may anastomosed about 30-40 cm distal to jejunum. This duct is about 0.4-0.5 cm thickness and the pancreas lysing enzymes flows through this duct to duodenum. In the operation this flow may provided to a lower zone and a 0.5 cm hole to jejunum will prepared. Then, the pancreatic duct may suturised with 6-0 or 8-0 number of prolene material to this hole. If this anastomosis will damaged after the procedure the patient usually dies. The damage rate is high, that may seen in 1 of 8 to 10 patients. Because, the lytic pancreatic enzymes have a tendency to lysis everything. Like this anastomosis, choledoc duct may anastomosed 10-15 cm distal from the pancreaticojejunostomy to jejunum also. The stomach will anastomosis to jejunum about 70-80 cm distal from other anastomoses to prevent alkaline reflux.
Open remains after pancreaticoduodenectomy.
Three anastomoses are created in this procedure.
The highest complication risk from this anastomosis is pancreaticojejunostomy. As a result, this open remains of this these ducts will connected to the appropriate small intestinal areas.
Surgical field bleeds are the first complication to occur. Then, surgical area infections can occur between 3 to 5 days. The rate of infection is relatively high because the stomach microbes and bile duct microbes can produce. Stomach slowdown can observed on 7 to 10 days after surgery and adversely affect the food intake of the patient. Removal of the distal pancreas can result in develop to diabetes mellitus in the late period also.
Postoperative complications will develop in %20 of patients. The most serious complication is pancreaticoduodenectomy anastomosis damage. This complication occurs in 1 of 10 patients and %90 of these patients will die. Other complications are complications that may occur in all intra-abdominal surgeries. These complications are like enteroenterostomy leak, hemorrhage, wound infections, etc. are all complications that can seen in intra-abdominal surgeries.
The survival time of pancreatic tumors is short, except for islet cell carcinoma. In pancreatic tumor patients, the survival time may 1-2 years even with appropriate chemotherapy. Survive of islet cell tumor patients can be up to 6-8 years after whipple procedure. Surviving time of malignant carcinoma of the main bile duct called Klatskin’s tumor is very short and survival for 6 months to 1 year is a good time.